Development of the European Laparoscopic Intermediate Urological Skills LUSs2 Curriculum: A Delphi Consensus from the European School of Urology

Take Home Message The European laparoscopic intermediate urological skills curriculum LUSs2 is the first development of an intermediate laparoscopic curriculum in urology. The combined approach, uniting a cognitive task analysis and Delphi consensus, facilitated the creation of a robust and finely tuned surgical training curriculum with the collaborative spirit that dives into medical education led by experts.


Laparoscopic urological training and curricula
Proficiency in minimally invasive surgery, particularly in laparoscopy, is crucial for attaining surgical excellence and ensuring the best patient outcomes in urology [1].The field's constant evolution, marked by new technologies and surgical techniques, necessitates adaptive training methodologies.The European School of Urology's (ESU's) introduction of the European Basic Laparoscopic Urological Skills programme in 2011 was a significant step in this direction, but the lack of established and internationally validated curricula for intermediate and advanced laparoscopic skills is evident [2].

Benefits of standardised surgical training
The traditional Halsted model of ''see one, do one, teach one'' is increasingly being replaced by preoperative training models, including online materials, workshops, and training models [1].Simulation-based training, common in high-risk professions, is particularly beneficial for rehearsing complex surgeries, allowing for skill refinement before the actual operations.This approach aligns with technological advancements and addresses the urgent need for standardised training methodologies in laparoscopic urology.

Lack of curricula and standardised training
Despite laparoscopy's recognised role in urology, disparities in training, particularly in laparoscopic exposure, are evident [3,4].These disparities are more pronounced in certain regions, highlighting geographical inconsistencies in training standards [3][4][5].The absence of advanced curricula underscores the need for a more structured approach to training in complex laparoscopic procedures.

Importance of consensus for surgical training
Establishing a consensus on training protocols, particularly with simulation models, is crucial [1].A cognitive task analysis (CTA), developed initially in the military, offers a methodology for deconstructing the cognitive processes in each critical phase of a procedure [6].Evidence suggests that a CTA-based instructional approach is superior in culti-vating procedural knowledge and technical skills to conventional methods [7][8][9].This study aims to develop and validate an intermediate laparoscopic urological skills curriculum to establish uniformity and facilitate proficiency in commonly performed urological laparoscopic procedures.

CTA development
A steering group of urologists involved in educational and surgical simulation activities (P.Z., T.R.O., G.P., J.G.R., H.d. V., C.B., W.B., T.S., M.R.S., and D.M.C.) within the European Association of Urology (EAU) and the ESU embarked on a series of collaborative meetings to meticulously craft a laparoscopic intermediate urological skills (LUSs2) curriculum using an in-depth CTA methodology.This curriculum involved intricate dissection of five distinct CTAs, meticulously outlining the sequential stages and essential equipment for specific tasks integral to the key laparoscopic urological surgical procedures.The specific tasks encompassed renal hilum dissection, major vessel injuries (MVIs), enucleation and renorrhaphy, vesicourethral (VU) anastomosis, and pyeloplasty.These CTAs were initially drafted by renowned experts (renal hilum dissection: A.S., B.P., and D.V.; MVI: D.V., A.S., and F.G.; enucleation and renorrhaphy: D.V., A.S., and G.P.; VU anastomosis: R.R.T.-B., R.S.-S., and M.A.-M.; and pyeloplasty: A.S., M.A.-M., and P.Z.), with the final objective to be replicated within a hands-on training framework in simulators for training and evaluation.All steering group members meticulously reviewed and adapted all CTAs before their formal approval.

Two-round Delphi survey
Upon the competition and endorsement of the LUSs2 curriculum, our focus shifted to validation, prompting us to engage an array of international experts using the Delphi methodology.All CTAs were transformed into Delphi statements, facilitated by the online software Welphi (Welphi.com;Decision Eyes, Lisbon, Portugal).This process involved the creation of five different questionnaires, each aligned with a specific CTA, accompanied by a space for comments in each statement.We employed a Likert scale spanning the spectrum from 1 to 9. A score of 1 represented ''strongly disagree'', while 9 indicated ''strongly agree''.We classified scores of 7, 8, and 9 as indicating agreement; 1, 2, and 3 as indicating nonagreement; and 4, 5, and 6 as denoting uncertainties.
Experienced urologists in laparoscopic surgery from various sections of the EAU and different countries were invited via e-mail to participate in the Delphi consensus.To ensure the integrity of the process, participants' identities and responses were protected, ensuring anonymity throughout the entire procedure.An experienced urologist in laparoscopic surgery was defined as a urologist with experience in the field of urological laparoscopy with significant hands-on experience with >5 yr of experience and >100 laparoscopic procedures per year, or >10 yr of experience with >50 laparoscopic procedures per year.
The first round was conducted from April 25 to May 25, 2023.The steering group analysed the results and comments, revising and resending the statements that did not reach an agreement.A second round was planned for these statements, involving a thorough review of comments and refinement to facilitate potential consensus.
The second round took place from June 26 to July 31, 2023.During this round, experts were informed of the consensus reached in the first round and the revised statements, including those with comments or edits as decided by the steering group.

Consensus meeting
Following the two rounds of the Delphi survey, statements that did not achieve consensus were presented for a vote to the expert panel during an online consensus meeting on November 22, 2023.The invited experts participated, where statements were subjected to a simple vote to deter-mine ''agreement'' or ''disagreement'' based on the previously established >70% threshold.

Literature review
The following question was reviewed: What is the current status of laparoscopy in urology in terms of training, standardisation, complications, and specific techniques such as renal hilum dissection, main vessel injuries, renal tumour enucleation, laparoscopic VU anastomosis, and pyeloplasty?
The literature also discusses various training methods for residents and novices, such as box trainers and simulators.Studies suggest that practice through structured training can lead to skill retention and potentially improve proficiency.However, the optimal method and the extent to which such training translates into clinical practice remain subjects of on-going research and debate.
It is evident that while the steep learning curve and effort required to achieve proficiency in laparoscopic surgery are recognised, the approaches to training vary significantly, and there is a persistent call for standardisation and improvement in training programmes.

Development of CTAs and Delphi statements
The steering group identified five complex laparoscopic tasks described in five different CTAs (Supplementary material).The essential key cognitive steps and decision-making processes of all CTAs were formulated into clear and concise Delphi statements so that the experts could evaluate and provide feedback on these.The statements were organised in a structured manner that reflected the sequence of cognitive processes involved in each task.

Two-round Delphi survey results
Figure 2 shows the Delphi consensus flowchart for the survey.Table 1 presents the characteristics of the respondents.On average, 61 experts from 17 countries participated in the Delphi consensus, including Belgium, the Netherlands, Italy, Portugal, Germany, Spain, Greece, Turkey, and the UK.The overall response rate was 84%.A detailed breakdown of the participant numbers in each Delphi round can be found in Supplementary Table 1.

Part I: hilum dissection
In this section, 38 of 50 (78%) statements reached agreement in the first round and four more in the second round, six statements were edited, and in the end, seven statements were discussed at the consensus meeting.The summary of statements regarding renal hilum dissection is shown in Table 2.There was an agreement regarding the usefulness of equipment such as atraumatic graspers, Maryland dissecting forceps, bulldog clamps, Hem-O-Lok clips, and suction-irrigation devices.There was also agreement that dissection can be considered complete when each vessel is sufficiently freed to safely place three Hem-O-Lok clips, a bulldog clamp, or tourniquets (in case of partial nephrectomy under warm ischaemia) with or without preservation of the adrenal gland, depending on the procedure.In the retroperitoneal approach, the Gaur balloon could be useful to create the operative field; the renal artery is the first to be identified, the psoas is the constant anatomical landmark, and the identification of the vena cava/aorta will help in easier finding of the hilum.There was no consensus on the imperative need to have instruments such as Satinsky clamp, Crawford clamp, EndoGia stapler, clips, or blood vessel sealing devices available.

Part II: MVI
Of the 48 statements, 44 (91%) reached agreement in the first round, 1 was edited for round 2, and two more statements were added; three statements reached agreement in round 2, and finally, three that did not reach agreement were discussed at the consensus meeting (Table 3).
In case laparoscopic MVI repair is needed, it is recommended that a laparoscopic Satinsky clamp, laparoscopic Crawford clamp, Hem-O-Lok clips (sizes M-L, L, and XL), two needle holders, and bipolar energy devices be prepared.
The statement regarding a closed suction drain to be left at the end of the surgery did not reach agreement in any of the rounds or consensus meetings.For round 2, two more statements were added and approved: one about leaving a drain and the other about leaving a passive suction drain.We consider these useful advice for laparoscopists.However, there was no consensus about the need for prepared ultrasound energy devices or leaving a suction drain at the end of MVI repair.

Part III: enucleation and renorrhaphy
Seventy-four statements were drafted initially for this section, 67 reached consensus in round 1 (90%), five were edited, and five were added for round 2. In round 2, five statements reached an agreement, and seven were discussed in the consensus meeting.
There was consensus on the usefulness and availability of equipment such as bipolar forceps, suction-irrigation devices, monopolar scissors, needle holders, and bulldog forceps or tourniquets.In addition, there is consensus that laparoscopic enucleation and renorrhaphy can be performed transperitoneally or retroperitoneally.The preferred route should be chosen according to the location of the renal lesion and the surgeon's experience.Zero ischaemia, warm ischaemia, selective/superselective clamping, and early arterial unclamping are viable options.Furthermore, monofilament suture is recommended for inner renorrhaphy, while no consensus was obtained for the type of suture for the outer renorrhaphy.Statements about the exposure technique, tumour excision, and renorrhaphy techniques are given in Table 4.

Part IV: VU anastomosis
Thirty-nine statements were initially proposed; 24 reached agreements (61%) in round 1.Four statements were edited for round 2, and three new statements were added.Round 2 included 18 statements, of which ten reached agreement.The remaining eight statements were discussed in the consensus meeting, and none reached an agreement.Regarding the required equipment, it was agreed that at least one needle holder is recommended for laparoscopic VU anastomosis and one 18-20F Foley catheter is needed for laparoscopic VU anastomosis.In addition, two unidirectional or one bidirectional barbed suture may be useful for laparoscopic VU anastomosis.It was agreed that knots should be done and kept outside the urethral lumen, and to inflate the balloon and test the integrity of the anastomosis by filling the bladder with 150 ml saline is useful at the end of the procedure.The VU anastomosis technique statements are available in Table 5.There was no consensus on the ideal needle for VU anastomosis.

Part V: pyeloplasty
Forty-two statements were drafted initially, 32 were approved in round 1 (76%), seven were edited, and ten were added for round 2; after round 2, six statements were approved, and ten were discussed in the consensus meeting (Table 6).About the equipment required, it was agreed that Maryland grasper, monopolar scissors, bipolar forceps, and a suction device are needed; at least one needle holder is recommended; and a balloon dilator is needed if retroperitoneal access is performed.Regarding the procedural steps, a good exposure of the ureteropelvic junction (UPJ) with cephalic dissection of the proximal ureter towards the pelvis is recommended, the diseased UPJ is removed, and redundant tissue is excluded.However, a small flap may remain until the end of the procedure for traction.The anastomosis should be tension free, and the knots should be outside the lumen of the UPJ.There was no consensus that the correct placement of the JJ stent should be confirmed by fluoroscopy, flexible cystoscopy, or instilling a dye into the bladder.

Consensus panel expert meeting
In the online consensus expert panel meeting, 33 statements were discussed to find ''agreement'' or ''disagreement''.Nineteen experts participated in the meeting and voted; seven statements (21%) reached an agreement.Two statements, both in the pyeloplasty section, were in >70% disagreement: ''a suction drain is recommended'' and ''stenting should be done before pyeloplasty''.

Discussion
This study is the first of its kind, focusing on developing an intermediate laparoscopic urological skills curriculum known as LUSs2.Our group utilised a unique approach based on CTAs to meticulously describe the necessary equipment, the step-by-step technique, and the resolution of potential complications that may arise in various urological procedures.This method breaks down complex surgical procedures into discrete cognitive components, revealing cognitive processes crucial for successful execution.
Once the curriculum was formulated and discussed among the group and invited collaborators, our focus shifted to ensuring its validity and effectiveness.We employed the highly rigorous Delphi consensus methodology, a systematic process involving a panel of esteemed European experts within the urological laparoscopy domain.Through no more than two rounds of discussion and an additional consensus meeting, the panel reached an agreement on nearly all curriculum statements.Those that were not agreed upon are a matter of the surgeon's preference and do not impact this intermediate task's overall generalisability and degree of standardisation.This process allowed for a comprehensive evaluation of the curriculum's content, structure, and relevance, while providing a platform for these experienced surgeons to contribute their expertise further and refine the curriculum.
The escalating complexity of surgeries and the integration of advanced technologies such as laparoscopy, endoscopy, and robotics underscore the urgent need for standardised training curricula.With limitations in trainee working hours, heightened expectations for operational results, and the imperative to reduce complications and hospital stays, the importance of effective training methods, including cadaveric, animal, and virtual simulations, is magnified.However, these methods are often costly and inac-      Data from a survey conducted by the European Society of Residents in Urology noted that only 44% of surveyed residents had a training centre for simulation in laparoscopy, and only 67% had participated in practical courses on laparoscopy [3].Although these data could be influenced by the progressive availability of robotic surgery in some residency programmes, the lack of laparoscopic training facilities and courses is evident.The same study found a positive association between training course participation and confidence in performing surgeries [3].Studies estimate that around 70% of vital steps can be missed when taught by experts in lectures [9].This may result from automation when surgeons reach the expert level.This could significantly affect the teaching process as experts may lose their conscious awareness of certain parts of procedures.Moreover, being an expert surgeon or having mastered surgical techniques does not translate into being an expert teacher and having a vocation as an educator [45].
Given these challenges, we advocate for the initial integration of CTAs into all surgical learning programmes.Compared with other motor-based interventions, CTAs offer several benefits, including ease of administration, cost effectiveness, and significant training impact [9].We recommend prioritising cognitive skills before psychomotor skills training, with CTAs and hands-on courses complementing operating room training.
While our study makes significant strides in developing and validating an intermediate laparoscopic urological skills curriculum, it has limitations, particularly our reliance on survey-based data.First, the response rate and the inherent selection of respondents can affect the generalisability of our findings.Additionally, the phrasing of statements and the range of response options can lead participants towards specific answers.Lastly, while surveys provide valuable insights into the perceptions and experiences of experts, these do not capture objective measures of competency improvement.Despite the limitations, the Delphi consensus process proved to be an effective validation mechanism, allowing for the synthesis of diverse expert opinions.Its anonymous nature prevented any dominant influence, ensuring a true consensus.The process was managed efficiently through e-mails, negating the need for physical meetings.
Future studies should incorporate objective, performance-based assessments to complement survey findings, providing a more rounded evaluation of the curriculum's impact on surgical proficiency.Looking forward, we are developing an examination and certification process for the LUSs2 curriculum.This initiative is a critical step towards formalising the competencies acquired through this innovative training framework, aligning with the broader goals of the EAU and the ESU to elevate the standards of urological surgical education and enhance patient care.

Conclusions
LUSs2 is the first development of a laparoscopic surgery curriculum in urology beyond the basic steps.The combined https://doi.org/10.1016/j.euros.2024.08.023 2666-1683/Ó 2024 The Authors.Published by Elsevier B.V. on behalf of European Association of Urology.This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

1 . 4 . 5 . 4 . 7 . 8 . 9 . 11 .
Always check images on CT or MRI first.Identify anatomy, best possible approach to the hilum, number of arteries/veins, and possible abnormalitiesIn the transperitoneal approach, the optimal way to perform dissection of structures is by an ascending Descendant or direct dissection is an alternative to the ascendant approach 7 10 85 AgreementHilum dissection transperitoneal approach round 1 Hilum dissection transperitoneal approach round 2 1. Rise up the lower kidney pole with the nondominant hand along with the ureter and gonadal vein (left side), to expose the psoas muscle and allow easier dissection of the fatty tissue The ureter and gonadal vein should be lifted up to allow easier and faster identification of the To ensure controlling the hilum before it bifurcates proximally to the kidney, it can be useful to move medially and search for the cava/ During vertical dissection of the perihilar fat, the renal vein is the first to show up in the majority of When the renal vein is first seen, its surface has to be considered as the new cleavage plane to be followed in order to take apart the fatty tissue and achieve a full vascular exposure 0 6 93 Agreement 10.A Maryland dissector can help in case of adhesions or a tight/absent cleavage plane over the Once the medial face of the renal vein is exposed fully, the posterior face can be freed with an angled dissector or (in case it is not available) the Maryland dissector.Any curved instrument might be useful 2 14 85 Agreement E U R O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0

7 . 11 87 Agreement 8 .
Before beginning dissection on the renal artery or vein, the horizontal positions of the major vessels (aorta on the left side, vena cava on the right: both parallel to the psoas) and vertical pulsations of the fat-covered renal artery laterally are looked for, and almost always visualised 2 One must remember that during renal retroperitoneoscopy, the psoas is the constant anatomic landmark.tomography; MRI = magnetic resonance imaging.E U R O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0

E 6 . 7 .
U R O P E A N U R O L O G Y O P E N S C I E N C E 6The assistant should be aware of having the optic lens clean and away from the bleeding points The assistant should be aware of applying the correct amount of pressure with the suction device

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U R O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0 cessible, emphasising the necessity for a validated, standardised curriculum.

2 . 3 . 4 .
Iodine and sterile cover should already be anticipated on a possible conversion before starting a The patient should preferably be moved to a supine position, and a midline incision should be made for adequate exposure of major vessels depending on the surgeon'In case of an injury with the patient in the lateral decubitus, patient should preferably be moved to the supine position to perform a subcostal (Chevron) incision for adequate exposure of major vessels depending on the surgeon'vessel injury.E U R O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0

E 4 . 5 . 6 . 8 . 12 . 14 . 15 . 18 .
U R O P E A N U R O L O G Y O P E N S C I E N C E 6 planning and approach Enucleation and renorrhaphy planning and approach 1. Preoperative planning based on imaging is mandatory before laparoscopic enucleation and renorrhaphy to check dimension, shape, exophytic/ endophytic proportions, distance from calyces, nearness to other structures, The preferred approach should be chosen in accordance with the location of the renal lesion and the experience of the and renorrhaphy: tumour exposition and excision Enucleation and renorrhaphy: tumour exposition and excision 1. Follow the same passage and technique of hilum dissection after thoroughly analysing the CT for arterial O P E A N U R O L O G Y O P E N S C I E N C E 6 Follow the cleavage plane between capsule and fat until the border of the tumour/adipose tissue covering the tumour (if the tumour is exophytic) In case of endophytic masses, the borders of the tumour are identified with US intraoperative guidance after defatting Mark the resection line all around the tumour edge according to the endoscopicout: take a minute to check that everything is ready: bulldog clamps or Rummel tourniquet, needle drivers, sutures (type and length, ready prepared), endoclips (Hem-O-Lok or similar) In case of small masses, clamping can be evaluated during enucleation according to the surgeon's experience and ability to control bleeding adequately, thus providing a Throughout the procedure, the assistant will provide a clean field by using suction, rinsing/flushing saline when needed, and/or pressing down any With nondominant hand gently lift the perirenal fat overlying the tumour, and with dominant hand make a sharp incision on the renal capsule 2on next page) E U R O P E A N U R O L O G Y O P E N S C I E N C E 6 border of the tumour 16.Widen the first sharp incision up to overall 5 mm, to allow easier identification of Pay attention to complex cysts to avoid any type of traction, and generally an enucleoresection should be preferred in these O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0 a-

5 . 6 .
O P E A N U R O L O G Y O P E N S C I E N C E 6 Pull the sutures with gentle traction on each thread (simultaneously or alternatively) in order to bring the bladder neck adjacent to the urethra without leaving a gap within the dorsal part of the anastomosis Avoid tearing the urethra by pulling the suture gently, upwards or laterally, and having the suture pass between the two jaws of the open needle holder placed adjacent to the urethra

2 . 6 . 8 . 8 . 2 .
Place the first suture inside out on the urethra and outside in on the bladder neck at the 5O P E A N U R O L O G Y O P E N S C I E N C E 6 four sutures symmetrically at the 4:00, 8:00, 2:00, and 10:00 o'clock positions outside in on the urethra and inside out on the Place four sutures symmetrically at the 4:00, 8:00, 2:00, and 10:00 o'clock positions outside in on the urethra and inside out on the bladder Place the final 2 sutures outside in on the urethra and inside out on the bladder neck at the 11Place the final 2 sutures outside in on the urethra and inside out on the bladder neck at the 11:O P E A N U R O L O G Y O P E N S C I E N C E 6 Besides the optic trocar, another 2 trocars are needed (1 Â 5 mm and 1 Â 10 mm trocars)

E 8 . 8 .
U R O P E A N U R O L O G Y O P E N S C I E N C E 6 double-J stent is passed through one of the trocars following the initially placed nitinol hydrophilic guidewire and advanced into the ureter and urinary The correct placement of the double-J stent should be confirmed by fluoroscopy (laparoscopic surgery) or flexible cystoscopy, or by instilling a dye into the The correct placement of the double-J stent should be confirmed by fluoroscopy (laparoscopic surgery) or flexible cystoscopy, or by instilling a dye into the O P E A N U R O L O G Y O P E N S C I E N C E 6 9 ( 2 0 2 4 ) 2 2 -5 0 pproach, uniting CTAs and Delphi consensus, not only facilitated the creation of a robust and finely tuned surgical training curriculum, but also enhanced the collaborative spirit that dives into medical education led by experts.

Table 1 -
Characteristics of the participants

Table 2 -
Summary of the statements regarding hilum dissection that were discussed and voted in round 1, round 2, and consensus meeting

Table 3 -
Summary of the statements about the assessment, handling, and repair of venous or arterial lesions (MVI) voted in round 1, round 2, and consensus meeting Pre-prepared 4-0 or 5-0 Prolene sutures with a knot at the tail and a Hem-O-Lok or Lapra-Ty clip should be ready (rescue stitch)

Table 4 -
Summary of the statements about the equipment, exposure technique, tumour excision, and renorrhaphy techniques for enucleation and renorrhaphy voted in round 1, round 2, and consensus meeting